People living with myasthenia gravis (MG) may face challenges when getting dental treatment. Symptoms such as trouble swallowing, neck weakness, or trouble breathing may make you wonder how to prepare for your next appointment.

As one MGteam member wrote: “I finally got a tooth pulled today. A back top molar that grew in sideways. I’ve had to cancel and cancel and cancel that appointment to the point where I stopped making them.”

In this article, we’ll discuss some of the common risks of dental treatment for people with myasthenia gravis. We’ll also cover what you can do to minimize those risks and make the next visit go more smoothly.

🗳️ Is your dental care complicated by your MG symptoms?

Yes, I avoid dental care due to my MG

Yes, my dentist and I do extra planning and take extra precautions

Yes, dental care often worsens my MG symptoms

No, my MG symptoms don’t complicate my dental care

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Risks of Dental Treatment for People With Myasthenia Gravis

Below are some of the common risks that people living with myasthenia gravis face when receiving dental care.

Procedures That Can Trigger Myasthenia Gravis Symptoms

Some dental procedures can worsen muscle weakness and cause fatigue in people with myasthenia gravis. Weakness in facial and chewing muscles may also make dental procedures more difficult. In some people with myasthenia gravis, lying back in a dental chair can cause the throat to close or fluids to be regurgitated.

Risk of Infection

People with myasthenia gravis may face a greater risk of dental infections, especially if they take immunosuppressants. Infections can trigger myasthenia gravis symptoms or make existing symptoms worse.

People with myasthenia gravis may develop gum infections. Although dental hygiene can be difficult, regular care at home can help prevent these infections. When oral infections are severe, they can worsen myasthenia gravis symptoms even if you don’t realize what’s causing the change.

Medications That Can Trigger Myasthenia Gravis Symptoms

Some medications commonly used during dental treatment may pose risks for people with myasthenia gravis. For example, certain medications can increase muscle weakness or affect breathing.

The sections below discuss medications that should be avoided or used with caution. Note that these aren’t complete lists. Always discuss any new medications with your doctor.

Before dental work, talk with your care team about medications that are generally best avoided in people with myasthenia gravis:

• Novocaine (procaine) — This local anesthetic can rapidly worsen muscle weakness in people with myasthenia gravis.
• Some antibiotics — Certain antibiotics can quickly worsen muscle weakness and are generally avoided in people with myasthenia gravis. Examples include azithromycin, erythromycin, clindamycin, ciprofloxacin, levofloxacin, and gentamicin.

These medications should be used cautiously depending on your myasthenia gravis symptoms:

• Anesthetics — Anesthesia choices require extra care, especially if myasthenia gravis affects your breathing. More details about anesthesia are discussed below.
• Central nervous system (CNS) depressants — These medications require caution in people with myasthenia gravis who have breathing difficulties. Examples include opioids, benzodiazepines, hypnotics, and barbiturates.

Possible Interactions With Myasthenia Gravis Medications

Several medications used to treat myasthenia gravis may complicate dental treatment. These include:

• Pyridostigmine (Mestinon) and neostigmine can increase saliva production. This may create challenges during procedures such as fillings and impressions for crowns or bridges.
• Cyclosporine is sometimes used to suppress the immune system in people with myasthenia gravis. It can cause gum overgrowth and interact with certain antibiotics and anti-inflammatory drugs.
• Azathioprine (Imuran) and prednisone suppress the immune system and may lead to oral infections. These medications can also delay wound healing.
• Newer targeted treatments, including efgartigimod alfa-fcab (Vyvgart), rozanolixizumab-noli (Rystiggo), and nipocalimab-aahu (Imaavy), may also increase the risk of infections.

Considerations for Dentures

People living with myasthenia gravis may have difficulty managing complete dentures. Weak muscles can make it hard to maintain a seal around an upper denture or keep a lower denture in place.

Dentures that don’t fit properly may worsen myasthenia gravis symptoms, such as:

• Trouble closing the mouth
• Dry mouth
• Difficulty chewing and swallowing
• Tongue fatigue
• Trouble speaking

For example, upper dentures that extend too far or have thick edges can press against muscles around your mouth, causing muscle fatigue and changes in saliva flow.

Other Ways To Reduce Risk From Dental Work

Preventive dental care is the best way to avoid dental emergencies. Regular dental visits for cleanings and other preventive care can help you avoid more major dental procedures.

Home care habits are also important, including regular brushing and flossing. If you’re having trouble with either of these, try using an electric toothbrush or floss holders.

Communicating With Your Dental Team

Good communication with your dental team is especially important when you have myasthenia gravis.

One MGteam member emphasized this point by saying: “When I was diagnosed with MG, I made sure my dentist and primary care provider knew. They both researched it and understand what my needs are. I’ve not had any issues with either one. Communication is a BIG must!”

Before your appointment, talk to your dental team about what the treatment involves. Discussing your limitations can help providers prepare for your appointment. For example, you may want to discuss:

• Chair position — People with myasthenia gravis may find it difficult to lie fully back. Sitting more upright may help reduce the risk of fluids backing up or your throat becoming blocked.
• Support devices — If you have trouble keeping your mouth open, a mouth prop may help. During certain procedures, a rubber dam can collect fluids around a tooth and help prevent choking.
• Suction — Having suction that you control during procedures can help with drooling and choking issues.

When possible, keep appointments short. For longer appointments, talk to your dentist about whether it’s possible to break them up into multiple sessions.

Scheduling Your Appointments

People with myasthenia gravis may prefer to schedule dental appointments in the morning or whenever they usually feel strongest.

“Planning is so important with MG. I have appointments regularly and schedule them from 10 a.m. until 2 p.m. only. I can’t be ready to travel before 9 a.m., and I’m too tired later in the afternoons.”

— MGteam member

It’s also recommended to have dental appointments one to two hours after taking oral anticholinesterase medications. This helps maximize the medication’s effects during your appointment.

Lastly, consider arriving early so you can give yourself time to rest. This may be especially helpful on hot days, when you may need to rest in air conditioning before your appointment.

Avoiding Drug Interactions

To reduce the risk of drug interactions during dental procedures, tell your dental team that you have myasthenia gravis and review your medications with them for any potential interactions. If you have significant breathing or swallowing problems or muscle weakness, ask your neurologist whether a hospital dental clinic would be safer.

If your procedure involves sedatives or antibiotics, your dentist should talk to your neurologist beforehand. If IV sedation or general anesthesia is needed for oral surgery, it’s recommended to have a dedicated anesthesiologist present so that the surgeon can focus on the procedure.